Reconstruction After Trauma

Common Procedures

Physical Indications: Complex Fractures

Complex fractures involve breaks where the bone is shattered (comminuted), penetrates the skin (open fracture), or involves a joint surface. These injuries disrupt the skeletal stability required for movement and weight-bearing. They often present with significant soft-tissue damage.

Reconstruction involves aligning the bone fragments and stabilizing them with internal hardware (plates, screws) or external fixators. This restores the limb’s length and alignment. Addressing the associated soft-tissue injury is critical to cover the hardware and prevent infection adequately.

• Comminuted and intra-articular fractures
• Open fractures with soft tissue loss
• Malalignment and limb length discrepancy
• Instability preventing weight-bearing
• Risk of osteomyelitis (bone infection)

Physical Indications: Soft Tissue Avulsion

Soft tissue avulsion occurs when skin and subcutaneous tissue are torn away from the underlying muscle or bone. This is common in “degloving” injuries from machinery or road rash. It leaves vital structures like tendons, nerves, and vessels exposed and vulnerable to desiccation and infection.

Reconstruction focuses on immediately covering these exposed structures. If the avulsed tissue is viable, it may be replanted. If not, skin grafts or flaps are used to provide durable coverage. The goal is to seal the wound and protect the deep anatomy.

• Degloving injuries of limbs or scalp
• Exposure of tendons, nerves, and vessels
• Loss of protective skin barrier
• Risk of desiccation and necrosis
• Requirement for durable flap coverage

Physical Indications: Amputations

Traumatic amputation is the complete severance of a body part. Replantation is the gold standard if the part is viable and the injury is clean (sharp cut). This involves microsurgical repair of arteries, veins, and nerves to restore blood flow and function to the severed part.

If replantation is not possible due to crush injury or contamination, reconstruction focuses on shaping the residual limb. This involves padding the bone end with muscle, ensuring good skin coverage, and preserving as much length as possible to optimize prosthetic fitting and function.

• Traumatic severance of digits or limbs
• Microsurgical replantation potential
• Revision of traumatic stumps
• Preservation of functional length
• Optimization for prosthetic interface

Biological Causes: Scar Contracture

Scar contracture is a biological response to deep injury, particularly burns. As the wound heals, myofibroblasts pull the edges together, shrinking the tissue. Over a joint, this creates a tight band that physically prevents full extension or flexion.

This biological process leads to functional disability. Reconstruction involves releasing the scar band (scar release) and introducing new tissue into the gap using Z-plasties or skin grafts. This restores the surface area needed for the joint to move through its full range of motion.

• Shortening and tightening of scar tissue
• Restriction of joint range of motion
• Distortion of the surrounding anatomy
• Functional limitation of limbs
• Requirement for surgical release and lengthening

Biological Causes: Non-Union of Bones

Sometimes, fractured bones fail to heal (non-union) due to poor blood supply, infection, or instability. This results in a persistent “false joint” that is painful and unstable. Biological factors like smoking or diabetes can contribute to this failure.

Reconstruction involves removing the scar tissue between the bone ends and filling the gap with a bone graft. This graft provides the biological scaffold and cells needed to stimulate healing. Sometimes, vascularized bone grafts (such as the fibula) are transferred to provide a new blood supply to the non-healing site.

• Failure of fracture healing (pseudarthrosis)
• Persistent pain and instability
• Biological lack of osteogenic potential
• Requirement for bone grafting
• Use of vascularized bone transfer

Biological Causes: Nerve Injury and Neuroma

• Trauma can sever or crush peripheral nerves, leading to loss of sensation and muscle paralysis. When a nerve is cut and not repaired, the cut end can form a painful ball of scar tissue called a neuroma. This biological response causes debilitating pain.

  Reconstruction involves repairing the nerve continuity or burying the painful nerve end deep in muscle. Nerve transfers rerouting a healthy nerve to do the job of a damaged one are used to restore function in cases where direct repair is impossible.

  • Loss of sensory and motor function
  • Formation of painful neuromas
  • Paralysis of target muscle groups
  • Requirement for neurorrhaphy (nerve repair)
  • Utilization of nerve transfers or grafts

Functional Issues: Hand Function

• The hand is a complex instrument of interaction. Trauma can disrupt the delicate balance of tendons, bones, and nerves. Stiffness, loss of grip strength, and loss of fine motor control are major functional issues.

  Hand reconstruction is highly specialized. It involves tendon repairs, fracture fixation, and joint releases. The goal is to restore the “functional cascade” of the fingers and the opposition of the thumb, allowing the patient to grasp, pinch, and hold objects.

  • Loss of grip and pinch strength
  • Stiffness and tendon adhesions
  • Disruption of the flexor/extensor mechanism
  • Sensory loss affecting dexterity.
  • Restoration of thumb opposition

Biological Causes: Nerve Injury and Neuroma

• Facial trauma can damage the facial nerve, leading to facial paralysis. This causes functional issues like the inability to close the eye (risking corneal damage), drooling, and difficulty speaking. It also causes significant asymmetry and loss of expression.

  Reconstruction aims to restore dynamic movement. This can involve nerve grafts, static suspension to support the face, or transferring muscles (like the temporalis) to reanimate the smile. Protecting the eye and restoring oral competence are the primary functional goals.

  • Facial nerve paralysis
  • Inability to close the eye (lagophthalmos)
  • Oral incompetence and speech difficulty
  • Loss of facial symmetry and expression
  • Reanimation via nerve or muscle transfer

Functional Issues: Walking and Gait

• Lower extremity trauma can compromise the ability to walk. Loss of muscle compartments, instability of the knee or ankle, or leg-length discrepancies can lead to a severe limp or an inability to bear weight.

  Reconstruction focuses on limb salvage and stability. This involves bone-lengthening procedures, muscle transfers to restore dorsiflexion (lifting the foot), and ensuring a stable, sensitive foot sole. The goal is a plantigrade foot that can support the body during gait.

  • Limb length discrepancy
  • Instability of weight-bearing joints
  • Drop foot from nerve/muscle loss.
  • Painful or unstable plantar surface
  • Restoration of efficient gait mechanics

Maxillofacial Reconstruction

• Trauma to the face often involves fractures of the orbit (eye socket), maxilla (upper jaw), and mandible (lower jaw). These fractures can cause double vision (diplopia), malocclusion (bad bite), and airway obstruction.

  Reconstruction involves accessing the fractures, often through incisions inside the mouth or eyelids, and fixing them with mini-plates. This restores the facial projection, protects the eye, and realigns the teeth for proper chewing function.

  • Fractures of the facial skeleton (Le Fort)
  • Diplopia (double vision) from orbital blowout
  • Malocclusion and chewing difficulty
  • Airway compromise from jaw fractures
  • Restoration of facial projection and symmetry

Thermal Burn Reconstruction

• Burns destroy the skin and its appendages. Deep burns result in thick, inelastic scar tissue that does not grow with the patient or stretch with movement. This leads to contractures and aesthetic deformity.

  Reconstruction is a lifelong process for burn survivors. It involves excision of scar tissue, skin grafting, and laser resurfacing to improve texture. Tissue expansion is often used to grow healthy skin to replace areas of alopecia (hair loss) or severe scarring.

  • Full-thickness skin destruction
  • Formation of hypertrophic burn scars
  • Contractures limiting mobility
  • Aesthetic deformity and texture changes
  • Staged excision and resurfacing

Consultation and Preparation

The Diagnostic Consultation Phase

During a trauma reconstruction consultation, the surgeon reviews emergency records and scans to understand the injury and any past repairs. The main goal is to see if the tissues are healthy enough for surgery and what kind of recovery is possible.

The surgeon checks the area around the injury for infection, poor blood flow, or hidden nerve damage. This helps decide if the focus will be saving the limb, restoring function, or improving appearance. The surgeon and patient talk openly about what results to expect and long-term goals.

• Review of trauma history and previous surgeries
• Assessment of tissue viability and infection status
• Evaluation of nerve and vascular integrity
• Discussion of salvage vs. amputation (if relevant)
• Establishment of functional and aesthetic goals

Advanced Imaging and 3D Planning

Standard X-rays are often insufficient for complex trauma. CT scans with 3D reconstruction are standard for evaluating facial fractures or complex limb injuries. These scans allow the surgeon to rotate the image and view the fractures from every angle, enabling precise planning of the reduction and fixation.

For soft tissue and vascular assessment, CT angiography (CTA) or MRI is used. These modalities map the blood vessels, identifying which are intact and available for connecting flaps. This “vascular roadmap” is critical for avoiding surprises during microsurgery.

• 3D CT reconstruction for skeletal analysis
• CT Angiography (CTA) for vascular mapping
• MRI for soft tissue and nerve evaluation
• Pre-operative virtual surgical planning
• Identification of perforator vessels for flaps

Physical Assessment: Vascular Status

The blood supply is the lifeline of any reconstruction. The surgeon palpates pulses and checks capillary refill. In the extremities, the Allen’s test (for hands) or Ankle-Brachial Index (ABI) might be performed to assess arterial flow.

For planned flaps, a handheld Doppler probe is used to locate specific “perforator” vessels that will supply the tissue. Marking these vessels on the skin beforehand ensures the surgeon knows exactly where the blood supply enters the flap, increasing the safety and speed of the harvest.

• Palpation of distal pulses
• Allen’s test and capillary refill assessment
• Ankle-Brachial Index (ABI) measurement
• Handheld Doppler mapping of perforators
• Assessment of venous outflow

Physical Assessment: Nerve Function

A detailed neurological exam is mandatory. The surgeon tests for sensation (light touch, two-point discrimination) and motor function (muscle strength) in the affected area. This establishes a baseline for measuring recovery.

In cases of nerve injury, identifying the lesion level is crucial. Tinel’s sign (tapping over the nerve to elicit tingling) helps locate the growing nerve end. This assessment determines if a nerve repair, graft, or transfer is indicated.

• Two-point discrimination testing
• Motor strength grading (0-5 scale)
• Tinel’s sign elicitation
• Mapping of sensory deficits
• Electromyography (EMG) review, if available

Surgical Readiness: Infection Control

Trauma wounds are often contaminated. Surgical readiness hinges on controlling infection. The surgeon assesses the wound for signs of active disease, such as redness, pus, or odor. Cultures may be used to identify specific bacteria.

If an infection is present, reconstruction is delayed. The patient may require debridement (cleaning) and antibiotics. Operating on an infected bed is a recipe for failure, so “optimizing the bed” is a critical preparatory step.

• Assessment of wound bioburden
• Bacterial culture and sensitivity testing
• Pre-operative debridement requirements
• Optimization of antibiotic therapy
• Management of osteomyelitis risk

Smoking and Nicotine Cessation

• Nicotine narrows blood vessels, which is especially risky in trauma reconstruction because blood flow is already limited. Smoking greatly raises the chances of tissue loss, poor bone healing, and wound infections.

  Patients are strongly advised to stop using nicotine. Continuing to smoke can lead to losing the repaired tissue. For planned surgeries, doctors may delay the operation until the patient has quit nicotine to make the procedure safer.

  • Mandatory cessation of nicotine products
  • Risk education regarding flap loss and non-union
  • Impact on microvascular circulation
  • Timeline for cessation (immediate/4 weeks)
  • Verification via cotinine testing for elective stages

Nutritional Optimization

• After trauma, the body uses a lot more energy to heal. Poor nutrition can slow down recovery. Surgeons check blood tests like albumin to see if the patient is getting enough nutrients.

  Patients are usually given high-protein diets and supplements like zinc, vitamin C, and arginine to help wounds and bones heal. Good nutrition helps the body recover faster and more effectively.

  • Assessment of nutritional markers (Albumin)
  • High-protein and high-calorie dietary plan
  • Supplementation for wound and bone healing
  • Management of hypermetabolic demand
  • Hydration status optimization

Psychological Readiness and Support

• Trauma happens suddenly and can change a person’s life. Patients may feel grief, PTSD, or anxiety. Surgeons check how patients are coping emotionally and whether they have support. They also make sure patients are ready for the challenges of surgery and recovery.

  Checking for PTSD is important because surgery can bring back traumatic memories. Having support from family, friends, or counselors is crucial. Preparing for surgery means making sure the patient is mentally ready for the recovery process.

  • Assessment of emotional resilience and PTSD
  • Verification of the social support system
  • Management of anxiety and expectations
  • Referral to mental health professionals
  • Preparation for the rehabilitation commitment

Pain Management Planning

• Chronic pain is common after trauma. Pre-operative planning involves discussing pain management strategies. This includes a multimodal approach using nerve blocks, non-narcotic medications, and, if needed, a pain management specialist.

  It’s important to set realistic expectations. The aim is to keep pain under control, not to remove it completely. Doctors also plan how to reduce and stop strong pain medicines after surgery to avoid long-term dependence.

  • Multimodal pain control strategy
  • Coordination with pain management specialists
  • Reduction of pre-operative narcotic load
  • Expectation setting for post-op comfort
  • Prevention of long-term opioid dependency

Donor Site Planning

• If tissue needs to be moved for repair, the surgeon chooses and discusses the best place to take it from, like the thigh, back, or abdomen. They check these areas to make sure the tissue is healthy and the risks are low.

  Patients are told they will have another surgical site where the tissue is taken. The surgeon explains possible side effects like scarring, temporary weakness, or numbness, so patients can make an informed decision.

  • Selection of optimal donor tissue
  • Evaluation of donor site morbidity
  • Discussion of secondary scarring
  • Functional impact on the donor area
  • Patient consent for graft harvest

Logistical Planning for Rehabilitation

• Recovery from trauma reconstruction is heavily dependent on rehabilitation. The consultation involves planning for post-op therapy. Does the patient have access to a hand therapist? Will they need a wheelchair or crutches?

  Organizing these details ahead of time helps therapy start on schedule. Patients are reminded that surgery is only the beginning, and most of the recovery happens during therapy.

  • Coordination with physical/occupational therapy
  • Acquisition of mobility aids (crutches/wheelchair)
  • Arrangement of transportation for therapy
  • Home modification planning
  • Commitment to the rehabilitation schedule

Surgery and Recovery

Anesthesia and Positioning

Trauma reconstruction often requires general anesthesia, especially for lengthy microsurgical procedures or multiple fracture fixations. The anesthesia team carefully manages fluids and temperature to ensure optimal blood flow to the reconstructed tissues.

How the patient is positioned during surgery is very important. The surgeon needs to see both the injury and any donor sites, like the hip or thigh. Soft padding is used to protect the skin from sores during long operations. Sometimes, a tourniquet is used on a limb to reduce bleeding and make the surgery easier.

• Administration of general anesthesia
• Fluid and temperature management
• Strategic positioning for dual-site access
• Protection of pressure points
• Tourniquet use for hemostasis

Debridement: The First Step

The first step in trauma surgery is cleaning the wound, called debridement. The surgeon removes any dead, damaged, or dirty tissue. This can mean trimming skin edges, taking out loose bone pieces, and washing the area with lots of saline.

Radical debridement turns a dirty injury into a clean surgical wound. It’s safer to have a bigger, healthy wound than a small one that could get infected. Surgeons check if muscle and skin are healthy by looking for bleeding at the edges, known as the “paprika sign.”

• Excision of necrotic and devitalized tissue
• Removal of foreign bodies and debris
• Pulsed lavage irrigation
• Evaluation of tissue viability (bleeding)
• Conversion to a clean surgical wound

Skeletal Stabilization

If bones are broken, they are fixed first to provide a stable scaffold. The surgeon reduces (realigns) the fractures and secures them with titanium plates, screws, or intramedullary rods.

In cases of severe soft tissue swelling or contamination, external fixation may be used. This involves placing pins into the bone through the skin and connecting them with an external rod. This “damage control” stabilizes the bone while allowing access to the soft tissue wounds.

• Reduction and alignment of fractures
• Internal fixation with plates/screws
• Application of external fixators
• Restoration of skeletal length and stability
• Preparation of the bed for soft tissue

Nerve and Vessel Repair

Once the bone is stable, the surgeon addresses the neurovascular structures. Using an operating microscope, severed arteries and veins are reconnected to restore circulation. Nerve ends are identified and sutured together.

If there is a gap in the nerve or vessel, a graft is used. A vein graft (from the leg) can bridge an arterial gap. A nerve graft (from the leg) can bridge a nerve gap. This microsurgical phase is delicate and critical for limb survival and function.

• Microsurgical anastomosis of vessels
• Epineurial repair of severed nerves
• Interposition vein or nerve grafting
• Restoration of distal perfusion
• Protection of repairs with soft tissue

Tendon and Muscle Repair

Tendons are repaired using strong, non-absorbable sutures. The surgeon uses specific weaving techniques to ensure the tendon ends remain in place under tension. If muscle bellies are torn, they are approximated with loose sutures to encourage healing without strangulation.

In cases of tendon loss, a tendon transfer may be performed later, or a spacer may be placed to keep the tunnel open for future grafting. Early passive motion protocols are often designed to prevent repaired tendons from adhering to the scar.

• Tenorrhaphy (tendon repair) techniques
• Muscle belly approximation
• Tendon transfer or grafting considerations
• Prevention of adhesion formation
• Intraoperative testing of excursion

Flap Elevation and Inset

• To cover exposed structures, a flap is harvested. This could be a local rotational flap or a free flap from a distant site. The flap is carefully dissected to preserve its blood supply.

  The flap is then “inset” into the defect. The surgeon sutures it in place, ensuring there is no tension on the pedicle (blood supply). Drains are placed under the flap to prevent fluid collection. The flap provides the padding and vascularity needed to promote healing of the injury.

  • Harvest of fasciocutaneous or muscle flap
  • Preservation of the vascular pedicle
  • Tension-free inset into the defect
  • Placement of suction drains
  • Verification of flap perfusion

Skin Grafting

• For areas where a flap is not needed (muscle beds with no exposed bone/tendon), a skin graft is used. A thin layer of skin is harvested from the thigh using a dermatome.

  The graft is meshed to allow fluid drainage and secured over the wound. A bolster dressing or Wound VAC is placed over it to press it firmly against the bed, ensuring it “takes” (grows new blood vessels).

  • Harvest of split-thickness skin graft
  • Meshing for expansion and drainage
  • Fixation with staples or sutures
  • Application of a bolster or Wound VAC
  • Donor site dressing application

Advanced Dressings: Wound VAC

• Negative Pressure Wound Therapy (Wound VAC) is frequently used in trauma. A sponge is placed in the wound, sealed with film, and connected to a vacuum pump. This sucks out fluid, reduces swelling, and stimulates granulation tissue (healing tissue).

  It is used to prepare wounds for grafting or to secure skin grafts. It simplifies nursing care and accelerates the cleaning of complex wounds.

  • Application of negative pressure therapy
  • Removal of exudate and edema
  • Stimulation of granulation tissue
  • Splinting of skin grafts
  • Reduction of bacterial load

Immediate Post-Op Monitoring

• In the recovery room, monitoring is intense. For free flaps, the flap is checked hourly for color, temperature, and capillary refill to ensure the blood vessels are open. The limb is elevated to reduce swelling.

  Pulse oximetry or implantable Doppler probes may be used on the flap for continuous monitoring. Pain is managed aggressively to prevent stress-induced vasoconstriction.

  • Hourly flap viability checks
  • Limb elevation protocols
  • Doppler monitoring of vascular flow
  • Pain and temperature management
  • Prevention of pressure on the reconstruction

Hospital Stay and Discharge

• The hospital stay ranges from a few days to a few weeks. Patients are transitioned from IV to oral pain meds. Physical therapy begins early sometimes day 1 to prevent stiffness, even if it’s just moving non-injured joints.

  Before leaving the hospital, patients are taught how to care for their wounds and make sure they have equipment like crutches or a wheelchair. It’s also important to have support at home. Blood thinners may be given to prevent clots while the patient is less active.

  • Transition to oral analgesia
  • Initiation of physical/occupational therapy
  • Wound care education
  • DVT prophylaxis (blood thinners)
  • Coordination of home health needs

Maintenance and Results

The First Six Weeks: Protection Phase

The first six weeks are critical. Bones are knitting, tendons are healing, and flaps are establishing their blood supply. The repair is fragile. Strict adherence to weight-bearing restrictions and splinting protocols is mandatory.

Swelling can slow healing, so patients need to keep the limb raised. Activity should be limited to protect the repair. This time is called ‘active rest’ move what you safely can, but protect the healing area.

• Strict adherence to weight-bearing status
• Use of protective splints or casts
• Continuous elevation to control edema
• Protection of flap and graft sites
• Vigilance for signs of infection

Wound Care and Hygiene

It’s very important to keep surgical sites clean. If there are pins from external fixators, they need to be cleaned every day to prevent infection. Stitches from flaps should also be kept clean and covered.

Once grafts have taken (usually after 1 week), they must be kept moisturized as they lack natural oils. Patients are taught to perform sterile dressing changes if needed.

• Pin site care for external fixators
• Gentle cleansing of suture lines
• Moisturizing of skin grafts
• Sterile dressing change techniques
• Monitoring for redness or drainage

Physical Therapy: Range of Motion

Therapy often begins within days. “Passive” motion (the therapist moves the joint) keeps joints loose without stressing muscle repairs. “Active” motion (patient moves the joint) starts later once tendons are stronger.

Scar massage is initiated to prevent the skin from sticking to tendons and bones (adhesions). This is crucial in the hand, where gliding is essential. Therapy is a daily commitment.

• Passive Range of Motion (PROM) exercises
• Progression to Active Range of Motion (AROM)
• Scar massage to prevent adhesions
• Edema control techniques
• Desensitization of hypersensitive areas

Strengthening and Conditioning

Around 6-12 weeks, as bones and tendons solidify, strengthening begins. Resistance exercises rebuild atrophied muscles. Proprioception training (balance) helps prevent reinjury, especially after lower-limb trauma.

Work hardening programs simulate job tasks to prepare the patient for returning to work. The focus shifts from protection to function and endurance.

• Progressive resistance training
• Proprioception and balance drills
• Work hardening and functional simulation
• Cardiovascular conditioning
• Rebuilding muscle mass and endurance

Scar Management

Traumatic scars can be hypertrophic (raised) or contractures (tight). Silicone sheets and compression garments are used to flatten scars. Laser treatments can reduce redness and improve texture.

If a scar crosses a joint and limits motion (contracture), surgical release (Z-plasty) may be needed later. Sun protection is mandatory to prevent permanent dark discoloration of the new scars.

• Application of silicone sheeting/gel
• Use of compression garments
• Laser resurfacing for texture/color
• Surgical release of contractures
• Strict sun protection (SPF 50+)

Sensory Recovery and Neuromas

• Nerves heal slowly, about one millimeter per day. As feeling comes back, patients may notice tingling, shocks, or itching. Desensitization therapy means gently rubbing the area with different textures to help the brain get used to new sensations.

  If a painful lump called a neuroma develops, it might need an injection or minor surgery. Patients who have numb areas need to be careful to protect them from burns or cuts, since they may not feel injuries there.

  • Management of paresthesias (tingling)
  • Desensitization protocols
  • Monitoring for painful neuromas
  • Protection of insensate areas
  • Sensory re-education exercises

Hardware Management

• Titanium plates and screws are generally left in forever unless they cause problems. In some cases, hardware becomes palpable or painful in cold weather. If so, it can be removed once the bone is fully healed (usually 12+ months).

  External fixators are taken off in the clinic once the bone is strong enough. The pin sites usually heal fast and leave only small scars.

  • Monitoring for hardware irritation/pain
  • Removal of symptomatic hardware (elective)
  • Removal of external fixators
  • Assessment of bone union before removal
  • Management of cold sensitivity

Long-Term Functional Adaptation

• Some injuries cause lasting changes. Patients may need to adjust to new limits, like using special tools for daily tasks, changing shoes, or wearing braces to help with walking.

  The main goal is to help patients be as independent as possible. They learn new ways to do everyday things. Regular check-ups make sure they are adjusting well and help catch any late problems, like arthritis.

  • Use of adaptive equipment/orthotics
  • Gait training and modification
  • Vocational rehabilitation
  • Monitoring for post-traumatic arthritis
  • Maximizing independence in ADLs

Psychological Recovery

• Recovery involves both the mind and body. PTSD or anxiety can last for some time. Support groups or counseling can help, and celebrating small steps forward keeps patients motivated.

  Acceptance of the “new normal” is a process. The reconstructive team supports the patient in integrating the injury into their life story without letting it define them.

  • Ongoing management of PTSD/anxiety
  • Support group participation
  • Acceptance of altered body image
  • Celebration of functional milestones
  • Holistic reintegration into society

Secondary Revisions

• Reconstruction often needs more than one surgery. Later procedures are common to improve the results. These can include thinning a thick flap, loosening a tight scar, or moving a tendon to help with movement.

  These follow-up surgeries are planned to get the best possible outcome. They are usually less involved than the first surgery and focus on improving how things work and look.

  • Flap thinning and contouring
  • Scar revision and Z-plasty
  • Tendon transfers for function
  • Tenolysis (freeing stuck tendons)
  • Aesthetic refinements